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GPs advised not to rule out Lyme disease despite lack of tick bite

GPs should not rule out the possibility that a patient has Lyme disease if they present with symptoms but have no clear history of tick exposure, according to new draft NICE guidance.

GPs are advised to diagnose and treat patients for Lyme disease without doing further tests if they present with the characteristic circular rash, and to refer patients for further tests if their symptoms and history are not as clear cut.

The guideline, which is out for consultation with stakeholders and will be published in April 2018, will be the first on Lyme disease published by NICE.

It advises that Lyme disease should not be ruled out in patients with symptoms but no clear history of tick exposure, but also that doctors should be cautious about diagnosing the disease in patients without a supportive history, as they may be missing an alternative diagnosis.

The guideline recommends that patients with a circular red rash (erythema migrans), should be diagnosed and treated with antibiotics without further investigation. Patients with symptoms that could represent Lyme, such as flu-like symptoms, joint or muscle pain or cognitive impairment, but no rash should be referred for further laboratory tests to rule it out.

It highlights that some patients with Lyme disease may find it difficult to explain their symptoms due to cognitive impairment and so GPs need to take a thorough history to help identify the cause.

Saul Faust, professor of paediatric immunology and infectious diseases at the University of Southampton and chair of the guideline committee, said: ‘Lyme disease may be difficult to diagnose as people can have common and unspecific symptoms, like a headache or fever, and they may not notice or remember a tick bite.

‘Our draft guidance will give GPs and hospital doctors clear advice on how to diagnose if they think Lyme disease is a possibility.

‘We also recommend tests used for this illness meet certain laboratory criteria. This is to make sure a potential diagnosis is based on clinically relevant and robust test results.’

Guideline in full

Be aware that Lyme disease is transmitted through the bite of an infected tick and that most tick bites do not transmit the disease

Diagnose without doing further investigation in patients with erythema migrans, usually at the site of the bite

  • Treat first line with a course of doxycycline in patients aged 12 or over

Consider Lyme disease in patients presenting with symptoms such as headache, flu-like symptoms and joint pain but no rash

  • Refer patients for ELISA and immunoblot laboratory tests
  • Consider repeating the tests 4-6 weeks later if the ELISA is negative but symptoms are persisting
  • If symptoms persist, consider referring to an infectious diseases specialist

Be aware that patients may have symptoms of cognitive impairment and therefore find it difficult to explain their symptoms 

Ask patients presenting with symptoms suggestive of Lyme disease about how long they have had them and about their travel history

Don't rule out Lyme disease in patients with symptoms but no clear history of tick exposure

  • Be cautious about diagnosing Lyme disease as symptoms may be pointing to an alternative diagnosis

Don't diagnose Lyme in patients with a tick bite but no symptoms 

Source: NICE


Readers' comments (14)

  • National Hopeless Service

    Lyme disease is becoming the new ME

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  • Hmmmmm.

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  • What a piece of luck I've read this article. Joint pains, headache, flu like symptoms, no rash - I've has that all day. Temperature 37.3. And I walked the dog yesterday.
    Obviously need lots of tests now as advised by the buffoons - sorry boffins (its the cognitive impairment) - at NICE. I might never work again.
    And here's me thinking as a typical GP that its 'just a virus'.

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  • Vit D levels are soooo last year darling....Lyme serology is the place to be!

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  • Dear All,
    add to all the above, "refer for investigations". What investigations, there are none except for a brain biopsy. Hmm, i think its likely to be a virus but have a brain biopsy. Nice.

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  • Just to get this straight- people with flu like symptoms without ANY history suggestive of a tick bite should be considered for lyme disease.
    Is there another discriminator we can use or should ALL these patients be tested for lyme disease. If so is the lab aware of the MILLIONS of extra tests that will need processing, 1 or 2 per person per year.

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  • Cognitive impairment- Does that include giving rambling non-specific useless advice?....Southampton is rather close to the new Forest..... if you look at the serology of those who live in the area, forestry workers to be precise, about 25% are serologically positive for lyme disease, but most will not report arthritis nor going gaga, so mild / asymptomatic disease is likely common. Therefore a positive test might not actually account for the patients symptoms. I spoke to my goldfish to get a think-tank opinion and he said... ' just give em 2 weeks of doxycycline if they live in a high risk area and see what happens. This might avoid 4-6 weeks of a spirochete chewing on your brain if theres a false negative... and if they get better, jobs a good un and you can apply to be on the next series of House, and, if they don't, then its likely not active lyme disease.....might be cheaper than an Elisa test, and save you spending hours on the phone to your local infectious disease consultant trying to get the test organised when he/she is wondering WTF and why this is the 50th test you've sent in this month when theres an influenza outbreak going on. Is this advice sponsored by the manufacturers of the testing kit?

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  • surely simpler/cheaper to issue everyone with these nonspecific sx-i.e 50% of this morning's surgery - a course of doxycycline then consider other diagnoses in everyone who doesn't get better?

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  • AlanAlmond

    What about people with no symptoms and no rash, but who went for a walk in a field, have read about Lymes disease and want to be tested because they believe they defiantly might have Lymes disease which you are defiantly probably going to miss because they have googled it and you are a stupid GP. What's the guidance on these people? I'm so glad NICE has issued guidance on this terrible condition the concern of which is absolutely rife amongst a sub group of worried dog walking googling, better educated than many, fairly well off concerned patients. Well over due. Thanks NICE.

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  • Your average Daily Mail reader is going to be all over this one.

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